The central dialysis fluid delivery system (CDDS): is it specialty in Japan?

Switching from acetate to citrate dialysate in a central concentrate delivery system for high-volume online hemodiafiltration: a retrospective cohort study

Interest in citrate-based dialysate (Cit-D) is growing due to its benefits, including anticoagulation and dialysis efficacy. However, research on safety and efficiency of Cit-D in high-volume hemodiafiltration (HDF) via central concentrate delivery system (CCDS) is scarce. This study aimed to investigate the safety and efficacy of Cit-D when switching from acetate-based dialysate (Acet-D) in high-volume HDF via CCDS. This is a retrospective analysis of 28 patients who underwent post-dilution online HDF via CCDS, who switched from Acet-D to Cit-D. The study period was divided into 3 periods for analysis: 12 weeks using Acet-D (AD period), the first 12 weeks using Cit-D (CD-1 period), and the second 12 weeks using Cit-D (CD-2 period). We collected the laboratory, dialysis, and safety parameters in each period from electrical medical records. After switching from Acet-D to Cit-D, heparin dosage decreased by 17%, whereas the incidence of complications did not increase. Kt/VBUN and urea reduction ratio increased by 4.6% and 2.1%, respectively. Pre-dialysis beta2-microglobulin concentration decreased after using Cit-D. The corrected calcium levels decreased in the CD-1 period compared to the AD period, but in CD-2, they subsequently increased to levels similar to those observed during the AD period. Symptomatic hypocalcemia did not occur, and there was no significant difference in the incidence of hyperparathyroidism. Endotoxin levels and the bacterial culture of ultrapure dialysate were unremarkable throughout all periods. These results might suggest that Cit-D could potentially offer advantages over Acet-D, such as reducing the heparin dose and increasing dialysis efficiency, in patients undergoing high-volume HDF using CCDS.

Evaluation of lipid profile, liver function enzymes, and trace elements in Iraqi diabetic nephropathy patients

Diabetic nephropathy, a common complication of type 2 diabetes (T2DM), is associated with abnormal lipid profiles, liver dysfunction, and kidney impairment. However, research on its association with trace elements in Iraqi patients is limited. The objective of the present study is to evaluate the association between lipid profile, liver function, and trace elements in diabetic nephropathy (DN) patients. In this study, 120 individuals were selected. Sixty of these individuals were labeled as the DN patient group, and 60 individuals were labeled as the healthy control group. A flame atomic absorption spectrophotometer (FAAS) was utilized to assess the levels of zinc (Zn), copper (Cu), and magnesium (Mg), whereas a flameless atomic absorption (FAA) was used to assess manganese (Mn). A colorimetric method was used based on the protocols included in the leaflets by Spinreact kits to determine the levels of lipid profiles and liver function enzymes in the serum. The mean value of high-density lipoprotein (HDL) decreased significantly in the DN patient group compared to the control group (p < 0.001) while cholesterol and low-density lipoprotein (LDL) decreased insignificantly. Conversely, the mean value of triglycerides (TGs) increased significantly in patient group ((p < 0.001) while very low-density lipoprotein (VLDL) increased insignificantly. On the other hand, the mean values of aspartate aminotransferase (AST), alanine transferase (ALT), alkaline phosphatase (ALP), and γ- glutamyl transferase (GGT) were significantly greater in DN patients compared to the healthy controls. Conversely, the mean values of total protein (TP) and albumin (Alb) were significantly lower in the DN patient group. In terms of trace elements, the mean values of Zn, Mg, and Mn were significantly lower in each of the patient groups compared to the healthy group. Conversely, a significant elevation in the means of Cu and Fe was observed in patients compared to the healthy group. Additionally, the findings revealed no association between BMI and lipid profile, liver enzymes, or trace elements. However, an association with age was limited to TGs, ALP, and GGT. The study's results show that the DN patients have abnormalities in their serum trace element levels. This means that these elements could be valuable indicators for monitoring and assessing the progression of DN. Understanding the correlation between lipid profile, liver function, and trace elements could offer valuable insights for managing and preventing diabetic nephropathy. More extensive studies, including an additional group of DM patients without nephropathy complications, are required, and could be used in practice due to the progression of the disease.

The influence of chronic renal insufficiency on multi-therapeutic modalities for breast cancer: a single-center experience

BACKGROUND

Due to the presence of other comorbidities and multi-therapeutic modalities in breast cancer, renally cleared chemotherapeutic regimens may cause nephrotoxicity. The aim of this retrospective study is to compare the chemotherapy types and outcomes in breast cancer patients with or without chronic renal disease.

PATIENTS AND METHODS

We retrospectively enrolled 62 female patients with breast cancer and underlying late stages (stage 3b, 4, and 5) of chronic kidney disease (CKD) treated from 2000 to 2017. They were propensity score-matched 1:1 with patients in our database with breast cancer and normal renal function (total n = 124).

RESULTS

The main subtype of breast cancer was luminal A and relatively few patients with renal impairment received chemotherapy and anti-Her-2 treatment. The breast cancer patients with late-stage CKD had a slightly higher recurrent rate, especially at the locally advanced stage. The 5-year overall survival was 90.1 and 71.2% for patients without and with late-stage CKD, but the breast cancer-related mortality rate was 88.9 and 24.1%, respectively. In multivariate analyses, dose-reduced chemotherapy was an independent negative predictor of 5-year recurrence-free survival and late-stage CKD was associated with lower 5-year overall survival rate.

CONCLUSIONS

Breast cancer patients with late-stage CKD may receive insufficient therapeutic modalities. Although the recurrence-free survival rate did not differ significantly by the status of CKD, patients with breast cancer and late-stage CKD had shorter overall survival time but a lower breast cancer-related mortality rate, indicated that the mortality was related to underlying disease.

Amyloid-Like Assembly to Form Film at Interfaces: Structural Transformation and Application

Protein-based biomaterials are attracting broad interest for their remarkable structural and functional properties. Disturbing the native protein's three-dimensional structural stability in vitro and controlling subsequent aggregation is an effective strategy to design and construct protein-based biomaterials. One of the recent developments in regulating protein structural transformation to ordered aggregation is amyloid assembly, which generates fibril-based 1D to 3D nanostructures as functional materials. Especially, the amyloid-like assembly to form films at interfaces has been reported, which is induced by the effective reduction of the intramolecular disulfide bond. The main contribution of this amyloid-like assembly is the large-scale formation of protein films at interfaces and excellent adhesion to target substrates. This review presents the research progress of the amyloid-like assembly to form films and related applications and thereby provides a guide to exploiting protein-based biomaterials.

Ischemic tubular injury: Oxygen-sensitive signals and metabolic reprogramming

The kidneys are the most vulnerable organs to severe ischemic insult that results in cellular hypoxia under pathophysiological conditions. Large amounts of oxygen are consumed by the kidneys, mainly to produce energy for tubular reabsorption. Beyond high oxygen demand and the low oxygen supply, different other factors make kidneys vulnerable to ischemia which is deemed to be a major cause of acute kidney injury (AKI). On the other hand, kidneys are capable of sensing and responding to oxygen alternations to evade harms resulting from inadequate oxygen. The hypoxia-inducible factor (HIF) is the main conserved oxygen-sensing mechanism that maintains homeostasis under hypoxia through direct/indirect regulation of several genes that contribute to metabolic adaptation, angiogenesis, energy conservation, erythropoiesis, and so on. In response to oxygen availability, prolyl-hydroxylases (PHDs) control the HIF stability. This review focuses on the oxygen-sensing mechanisms in kidneys, particularly in proximal tubular cells (PTCs) and discusses the molecules involved in ischemic response and metabolic reprogramming. Moreover, the possible roles of non-coding RNAs (microRNAs and long non-coding RNAs) in the development of ischemic AKI are put forward.

Dialysate calcium, alfacalcidol, and clinical outcomes: A post-hoc analysis of the J-DAVID trial

The selection of dialysate calcium concentration (D-Ca) is still controversial among chronic hemodialysis (HD) regimens. We examined the trajectories of CKD MBD parameters among the J-DAVID trial participants to see the effect of D-Ca and alfacalcidol. The trial was an open-label randomized clinical trial including 976 HD patients with intact PTH of 180 pg/mL or lower which compared the users of vitamin D receptor activator (oral alfacalcidol) and non-users over a median of 4 years. The main D-Ca used at baseline were 3.0 mEq/L in 70% and 2.5 mEq/L in 25%, respectively. The primary endpoint was the composite of fatal and non-fatal cardiovascular events and the secondary endpoint was all-cause mortality. Multivariable Cox proportional hazard regression analyses in which D-Ca was included as a possible effect modifier and serum laboratory data as time-varying covariates showed no significant effect modification for composite cardiovascular events or all-cause mortality. This post hoc analysis showed that the effects of alfacalcidol on cardiovascular outcomes were not significantly modified by D-Ca.

Particulates formed in dialysis fluid: effect of silica in tap water

Background

A fluid commonly used for dialysis in Japan is prepared from two dialysate concentrates and dialysis water. Silicon (Si) from tap water is reported in dialysis water as suspended insoluble particulate matters. We aimed to examine the source of insoluble particulate matters in the online prepared substitution fluid and to examine effects of the silica (SiO2) of tap water on the SiO2 of dialysis water.

Method

Based on the number of particles and particle size distribution in online prepared substitution fluid, we evaluated particle diameters and constituent elements of particles in online prepared substitution fluid. To identify sources of insoluble particulate matters in the online prepared substitution fluid, we measured particle diameters and constituent elements of particles adhering to the surface of hollow fiber of the final endotoxin-retentive filter (ETRF) and to the inner surface of the housing of the final ETRF and measured SiO2 in tap water, dialysis water, and commercial sterile substitution fluid.

Results

Si-containing particles accounted for 83% of 30 particles detected in the final ETRF (the hollow fibers and the housing) and the online prepared substitution fluid sampled from the final ETRF. The large variability in the SiO2 in tap water depending on the geographic regions. The SiO2 in dialysis water was 0.4–0.7 mg/L. Si was not detected in particles in the commercial sterilized substitution fluid, and the commercial sterile substitution fluids contained SiO2 at 0.1 mg/L.

Conclusion

We presume that insoluble particulates in online prepared substitution fluid were calcium and magnesium precipitated from dialysate and Si precipitated from dialysis water. Moreover, variation in the SiO2 in tap water is a factor affecting the SiO2 level in dialysis water. If the formation of silicates in the online prepared substitution fluid is considered and the target SiO2 in dialysis water is to be set ≤ 0.1 mg/L, SiO2 in tap water available in hospitals and dialysis centers should be known before specifications of instruments for dialysis fluid preparation are determined.

Lethal ventricular arrhythmia can be prevented by adjusting the dialysate potassium concentration and the use of anti-arrhythmic agents: a case report and literature review

Background

Hypokalemia is common in patients with malnutrition undergoing hemodialysis and is often involved in the development of lethal arrhythmia. Moreover, hemodialysis therapy decreases the serum potassium concentration due to potassium removal to the dialysate. However, it is difficult to adjust the dialysate potassium concentration owing to the use of the central dialysate delivery system in Japan. Here, we have presented a case undergoing hemodialysis with dialysate potassium concentration adjustment to prevent ventricular arrhythmia.

Case presentation

A 56-year-old man with Emery-Dreifuss muscular dystrophy and chronic heart failure was admitted to our hospital and needed subsequent hemodialysis therapy due to renal dysfunction. During hemodialysis, the cardiac resynchronization therapy defibrillator was activated to the treatment of his lethal ventricular arrhythmia. Decreases in serum potassium concentration after hemodialysis and changes in serum potassium concentration during HD were considered the causes of lethal ventricular arrythmia. Therefore, along with using anti-arrhythmic agents, the dialysate potassium concentration was increased from 2.0 to 3.5 mEq/L to minimize changes in the serum potassium concentration during hemodialysis. Post-dialysis hypokalemia disappeared and these changes during hemodialysis were minimized, and no lethal ventricular arrhythmia occurred thereafter.

Conclusions

In this case, we prevented lethal arrhythmia by maintaining the serum potassium concentration by increasing the dialysate potassium concentration, in addition to the use of anti-arrhythmic agents. In the acute phase of patients with frequent lethal arrhythmia undergoing hemodialysis, an increase in dialysate potassium concentration may be an effective method for preventing arrhythmogenic complications.

Particulates formed in online prepared substitution fluid- Effect of acetic acid cleaning on endotoxin retentive filters

INTRODUCTION

There is no standard for insoluble particulate matters in dialysate. We evaluated the insoluble particulate matters in online prepared substitution fluid.

METHODS

We evaluated particle diameters and constituent elements of particles in online prepared substitution fluid and the final endotoxin retentive filter (ETRF).

RESULTS

The measurement results with particles in the online prepared substitution fluid and particles attached to the final ETRF revealed that Ca-containing particles accounted for 11 particles and Si-containing particles accounted for 19 particles of 30 particles detected in the online prepared substitution fluid and the final ETRF.

CONCLUSION

We presume that insoluble particulates in online prepared substitution fluid were Ca and Mg precipitated from dialysate and Si precipitated from dialysis water. Even if two ETRFs were connected in series, these particles were formed in the final ETRF.

Disinfectants in a Hemodialysis Setting: Antifungal Activity Against Aspergillus and Fusarium Planktonic and Biofilm Cells and the Effect of Commercial Peracetic Acid Residual in Mice

Aspergillus and Fusarium cause a broad spectrum of infections in humans, mainly in immunocompromised patients. Among these, patients undergoing hemodialysis are highly susceptible to infections, requiring a constant and adequate environmental disinfection program. Nevertheless, monitoring the residual disinfectants can contribute to the morbidity and mortality reduction in these patients. Here, we evaluated the susceptibility of Aspergillus spp. (n=19) and Fusarium spp. (n=13) environmental isolates against disinfectants (acetic acid, citric acid, peracetic acid, sodium hypochlorite, and sodium metabisulphite) at different concentrations and time exposures. Also, we investigated the in vivo toxicity of the peracetic acid residual concentration in mice. Fusarium isolates were identified by F. equiseti, F. oxysporum and F. solani while Aspergillus presented clinically relevant species (A. fumigatus, A. niger and A. terreus) and environmental ones. Against planktonic cells, only two disinfectants (acetic acid and sodium hypochlorite) showed a fungicidal effect on Fusarium spp., while only one (sodium hypochlorite) was effective against Aspergillus spp. Both fungi formed robust in vitro biofilms with large amounts of the extracellular matrix, as evidenced by electron micrographs. Exposure of fungal biofilms to disinfectants showed sensitivity to three (acetic, citric, and peracetic acids), although the concentrations and times of exposure varied according to the fungal genus. Mice exposure to the residual dose of peracetic acid during 60 weeks showed anatomopathological, hematological, and biochemical changes. The implementation of news control measures and those that already exist can help reduce infections, the second cause of death and morbidity in these patients, besides providing safety and well-being to them, a priority of any quality health program.

Loopholes in the Research Ethics System? Informed Consent Waivers in Cluster Randomized Trials with Individual-Level Intervention

Individual-cluster trials randomize groups of individuals but deliver study interventions directly to individual participants. We examine three arguments that might justify the perception that the bar for a waiver of consent should be lower in such trials than for individually randomized trials. We contend that if these arguments are treated as sufficient to grant a waiver of consent, then a loophole emerges in research oversight. Such loopholes are morally hazardous for study participants, the integrity of science, and public trust in the research enterprise. We conclude by articulating the standards that research ethics committees should use to evaluate requests for waivers of consent in individual-cluster trials.

Green nephrology and eco-dialysis: a position statement by the Italian Society of Nephrology

High-technology medicine saves lives and produces waste; this is the case of dialysis. The increasing amounts of waste products can be biologically dangerous in different ways: some represent a direct infectious or toxic danger for other living creatures (potentially contaminated or hazardous waste), while others are harmful for the planet (plastic and non-recycled waste). With the aim of increasing awareness, proposing joint actions and coordinating industrial and social interactions, the Italian Society of Nephrology is presenting this position statement on ways in which the environmental impact of caring for patients with kidney diseases can be reduced. Due to the particular relevance in waste management of dialysis, which produces up to 2 kg of potentially contaminated waste per session and about the same weight of potentially recyclable materials, together with technological waste (dialysis machines), and involves high water and electricity consumption, the position statement mainly focuses on dialysis management, identifying ten first affordable actions: (1) reducing the burden of dialysis (whenever possible adopting an intent to delay strategy, with wide use of incremental schedules); (2) limiting drugs and favouring "natural" medicine focussing on lifestyle and diet; (3) encouraging the reuse of "household" hospital material; (4) recycling paper and glass; (5) recycling non-contaminated plastic; (6) reducing water consumption; (7) reducing energy consumption; (8) introducing environmental-impact criteria in checklists for evaluating dialysis machines and supplies; (9) encouraging well-planned triage of contaminated and non-contaminated materials; (10) demanding planet-friendly approaches in the building of new facilities.

Efficacy and Safety of Evocalcet Evaluated by Dialysate Calcium Concentration in Patients with Secondary Hyperparathyroidism Undergoing Hemodialysis

Purpose

Evocalcet is a novel oral calcimimetic drug that has demonstrated similar efficacy to cinacalcet in regulating serum parathyroid hormone (PTH), calcium, and phosphate levels, with fewer upper gastrointestinal tract-related adverse drug reactions (ADRs) in patients with secondary hyperparathyroidism undergoing hemodialysis in Japan. We investigated the efficacy and safety of once-daily oral evocalcet under different dialysate calcium concentrations.

Patients and Methods

A post hoc analysis by dialysate calcium concentration (2.5, 2.75, and 3.0 mEq/L) was performed using data from a previous Phase 3 study that included cinacalcet as an active control. Efficacy endpoints were the proportion of patients who achieved the target intact PTH levels of ≥60 and ≤240 pg/mL between Week 28 and Week 30; time-course changes in serum intact PTH; calcium and phosphorus levels, bone turnover markers, and fibroblast growth factor 23 (FGF23) over the 30-week study period. Safety endpoints were overall ADRs and hypocalcemia- and upper gastrointestinal tract-related ADRs.

Results

A total of 634 patients were included in the analysis. Levels of intact PTH, calcium, phosphate, bone turnover markers, and FGF23 showed improvement in all sub-groups, irrespective of dialysate calcium concentration. The incidence of upper gastrointestinal tract-related ADRs was significantly lower in the evocalcet group than the cinacalcet group with dialysate calcium concentrations of 2.75 and 3.0 mEq/L (p<0.05 for both concentrations).

Conclusion

Evocalcet was effective and safe in regulating the levels of serum intact PTH, calcium, and phosphate in patients with secondary hyperparathyroidism undergoing hemodialysis, irrespective of dialysate calcium concentration.